Survival after subsequent non-Hodgkin's lymphoma and non-small cell lung cancer in patients with malignant thymoma

BACKGROUND

Survivors of malignant thymoma (MT) are at an increased risk of developing subsequent neoplasms. We compare overall survival (OS) between MT survivors who developed non-Hodgkin's lymphoma (NHL) or non-small cell lung cancer (NSCLC), and patients with first primary NHL (NHL-1) or NSCLC (NSCLC-1), respectively.

METHODS

Using the population-based Surveillance, Epidemiology, and End Results (SEER) database for 1973 through 2013, 273,313 patients who had NHL-1, 21 patients with MT-NHL, 566,819 patients with NSCLC-1, and 38 patients with MT-NSCLC were identified. Univariate and multivariate models were used to assess the impact of various factors on OS.

RESULTS

The observed-to-expected ratio among MT patients was 2.63 [95% confidence interval (95% CI), 1.40-4.49; P<0.05] for NHL and 1.90 (95% CI, 1.33-3.63; P<0.05) for lung cancer. On univariate analysis, MT history did not worsen OS for NHL [hazard ratio (HR), 1.46; 95% CI, 0.87-2.47; P=0.16] or NSCLC (HR, 0.89; 95% CI, 0.61-1.29; P=0.53). On multivariate analysis, MT history was found to be an adverse prognostic indicator on OS for NHL (HR, 2.03; 95% CI, 1.20-3.42; P=0.008), but not NSCLC (HR, 0.87; 95% CI, 0.60-1.25; P=0.45).

CONCLUSIONS

Patients who develop NHL after MT have inferior survival than those with first primary NHL. A history of MT does not have an adverse prognostic impact on subsequent NSCLC. Clinicians must be aware of the intrinsic risk for subsequent malignancies after MT and the potential adverse impact of MT history on NHL prognosis but not NSCLC.

Simple Factors Associated With Radiation-Induced Lung Toxicity After Stereotactic Body Radiation Therapy of the Thorax: A Pooled Analysis of 88 Studies

PURPOSE

To study the risk factors for radiation-induced lung toxicity (RILT) after stereotactic body radiation therapy (SBRT) of the thorax.

METHODS AND MATERIALS

Published studies on lung toxicity in patients with early-stage non-small cell lung cancer (NSCLC) or metastatic lung tumors treated with SBRT were pooled and analyzed. The primary endpoint was RILT, including pneumonitis and fibrosis. Data of RILT and risk factors were extracted from each study, and rates of grade 2 to 5 (G2+) and grade 3 to 5 (G3+) RILT were computed. Patient, tumor, and dosimetric factors were analyzed for their correlation with RILT.

RESULTS

Eighty-eight studies (7752 patients) that reported RILT incidence were eligible. The pooled rates of G2+ and G3+ RILT from all 88 studies were 9.1% (95% confidence interval [CI]: 7.15-11.4) and 1.8% (95% CI: 1.3-2.5), respectively. The median of median tumor sizes was 2.3 (range, 1.4-4.1) cm. Among the factors analyzed, older patient age (P=.044) and larger tumor size (the greatest diameter) were significantly correlated with higher rates of G2+ (P=.049) and G3+ RILT (P=.001). Patients with stage IA versus stage IB NSCLC had significantly lower risks of G2+ RILT (8.3% vs 17.1%, odds ratio = 0.43, 95% CI: 0.29-0.64, P<.0001). Among studies that provided detailed dosimetric data, the pooled analysis demonstrated a significantly higher mean lung dose (MLD) (P=.027) and V20 (P=.019) in patients with G2+ RILT than in those with grade 0 to 1 RILT.

CONCLUSIONS

The overall rate of RILT is relatively low after thoracic SBRT. Older age and larger tumor size are significant adverse risk factors for RILT. Lung dosimetry, specifically lung V20 and MLD, also significantly affect RILT risk.

Myxopapillary ependymoma: a SEER analysis of epidemiology and outcomes

Myxopapillary ependymoma (MPE) is an exceedingly rare tumor histology. While surgery is clearly the treatment of choice, controversy exists regarding the role of adjuvant radiotherapy (RT). Using the Surveillence, epidemiology, and end results (SEER) database, we aimed to determine the epidemiology, prognostic factors, and treatment-related outcomes for MPE. A total of 773 cases were found in the SEER database. The incidence in the American population was found to be 1.00 per million person-years. On multivariate analysis, receipt of surgery (HR = 0.14, CI = 0.06-0.35, p < 0.001), receipt of RT (HR = 4.06, CI = 1.87-8.81, p < 0.001), age less than 30 (HR = 0.24, CI = 0.08-0.72, p = 0.01), and Caucasian race (HR = 0.37, CI = 0.13-0.996, p = 0.049) were statistically significant prognostic factors. The mean tumor size among those receiving RT (4.6 cm) was significantly larger than among those not receiving RT (3.2 cm, p = 0.0002). Those who lived in metropolitan areas were more likely to receive RT than those who did not. Given multiple previous studies show that RT improves PFS and the discrepancy in tumor size, selection bias is likely a significant contributor to the apparent negative impact of RT on OS. Regardless, surgery remains the most crucial aspect in the care of patients with MPE.

Repeat courses of SRS in patients initially treated with SRS alone for brain-metastatic melanoma

Aim

Stereotactic radiosurgery (SRS) is often used in the treatment of brain metastatic melanoma. Little data exist regarding outcomes of repeat course of SRS in this population. We aimed to identify treatment outcomes and toxicities in melanoma patients treated with repeat SRS after upfront SRS.

Patients & methods

We reviewed ten consecutive patients treated with repeat SRS following upfront SRS alone for brain metastatic melanoma.

Results

The median overall survival from initial treatment was 17.5 months. The median overall survival from repeat SRS was 6.7 months with a 6-month local control rate of 80%. The majority of patients progressed systemically before death. Four patients reported six adverse events, all grade 1.

Conclusion

Prospective study regarding the safety and efficacy of repeat courses of SRS in patients with brain-metastatic melanoma, especially in combination with novel immunotherapies, is warranted.

Simple Factors Associated With Radiation-Induced Lung Toxicity After Stereotactic Body Radiation Therapy of the Thorax: A Pooled Analysis of 88 Studies

PURPOSE

To study the risk factors for radiation-induced lung toxicity (RILT) after stereotactic body radiation therapy (SBRT) of the thorax.

METHODS AND MATERIALS

Published studies on lung toxicity in patients with early-stage non-small cell lung cancer (NSCLC) or metastatic lung tumors treated with SBRT were pooled and analyzed. The primary endpoint was RILT, including pneumonitis and fibrosis. Data of RILT and risk factors were extracted from each study, and rates of grade 2 to 5 (G2+) and grade 3 to 5 (G3+) RILT were computed. Patient, tumor, and dosimetric factors were analyzed for their correlation with RILT.

RESULTS

Eighty-eight studies (7752 patients) that reported RILT incidence were eligible. The pooled rates of G2+ and G3+ RILT from all 88 studies were 9.1% (95% confidence interval [CI]: 7.15-11.4) and 1.8% (95% CI: 1.3-2.5), respectively. The median of median tumor sizes was 2.3 (range, 1.4-4.1) cm. Among the factors analyzed, older patient age (P=.044) and larger tumor size (the greatest diameter) were significantly correlated with higher rates of G2+ (P=.049) and G3+ RILT (P=.001). Patients with stage IA versus stage IB NSCLC had significantly lower risks of G2+ RILT (8.3% vs 17.1%, odds ratio = 0.43, 95% CI: 0.29-0.64, P<.0001). Among studies that provided detailed dosimetric data, the pooled analysis demonstrated a significantly higher mean lung dose (MLD) (P=.027) and V20 (P=.019) in patients with G2+ RILT than in those with grade 0 to 1 RILT.

CONCLUSIONS

The overall rate of RILT is relatively low after thoracic SBRT. Older age and larger tumor size are significant adverse risk factors for RILT. Lung dosimetry, specifically lung V20 and MLD, also significantly affect RILT risk.

Abstract OT3-03-04: NRG-BR002: A phase IIR/III trial of standard of care therapy with or without stereotactic body radiotherapy (SBRT) &/or surgical ablation for newly oligometastatic breast cancer

Background:

The current standard of care for metastatic breast cancer patients (pts) is to deliver palliative chemotherapy, biologic &/or hormonal therapy when appropriate, with radiation &/or surgery reserved for the management of symptomatic or non-responsive (mets). For selected pts with limited metastatic (met) disease, mets-directed ablative therapy, with either surgical resection or high dose conformal radiotherapy (in addition to standard systemic therapies) to lung, liver, CNS adrenal, & multiple organs has been shown to result in long-term disease control numerically superior to systemic therapy alone. NRG-BR002 is a randomized Phase II trial to evaluate stereotactic body radiotherapy (SBRT) &/or surgical resection (SR) of all met sites in newly oligometastatic breast cancer in addition to standard systemic therapy.

Trial Design & Eligibility

For the Ph IIR, eligible breast cancer pts who have received up to 6 months of first line systemic therapy without progression will be randomized to receive either standard systemic therapy with mets directed therapy as needed ( control arm) versus ablative therapy of all met sites with either body SBRT &/or surgical resection (SR) ( per the treating physician discretion) to determine if there is an improvement median progression free survival (PFS). If this aim is met the trial continues as a Ph III to evaluate if SBRT/SR improves 5 year overall survival. Secondary aims include local control in the met site, new distant met rate, & technical quality. The primary translational endpoint tests whether &lt; 5 CTCs (per 7.5ml of blood) is an independent prognostic (outcome) marker for improved PFS & OS in oligometastatic breast cancer.

Women with pathologically confirmed met breast cancer to &lt; /= 2 sites, with up to 6 months of standard first line systemic therapy & the primary site disease is controlled. CNS mets are ineligible. ER/PR & HER-2 neu are required on either the primary or met site. Site radiation credentialing & a facility questionnaire are required. Randomization is to standard systemic therapy with local radiotherapy/ surgery for palliation when necessary vs ablative therapy of all mets with SBRT &/or SR.

Statistics:

For the Ph IIR portion to detect a signal for improved median PFS from 10.5 months to 19 months with 95% power & accounting for ineligible/lost pts, 146 pts will be required. For the Ph III, an additional 246, for a total of 402 pts will be required to definitively determine if ablative therapy improves 5-year overall survival from 28% to 42.5% (HR=0.67), with 85% power & a 1-sided type I error of 0.025. For the translational research, the number of pts accrued in the Ph IIR & Ph III portions will provide sufficient power ≥ 91% to detect whether &lt; 5 CTC's is a prognostic marker for improved PFS & OS.

Present Accrual & Target Accrual

NRG BR002 activated 12/24/2014 with a target accrual of 146 pts for the Ph II component & 256 additional for the Ph III.

Contact Information:

Protocol: CTSU member web site https://www.ctsu.org. Enrollment: OPEN at https://open.ctsu.org.

Support:

Supported by NRG Oncology grants U10CA180868 & U10CA180822 from the National Cancer Institute (NCI).

Citation Format: Chmura SJ, Winter KA, Salama JK, Woodward WA, Borges VF, Al-Hallaq H, Matuszak M, Jaskowiak NT, Milano MT, Bandos H, White JR. NRG-BR002: A phase IIR/III trial of standard of care therapy with or without stereotactic body radiotherapy (SBRT) &/or surgical ablation for newly oligometastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-03-04.

Evidence table development as a novel teaching tool in cancer survivorship education

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Background: We established a novel curriculum in Cancer Survivorship Education (CSE), as a collaborative effort between our accredited training programs in Hematology/Oncology and Radiation Oncology. The conceptual framework for all our coursework in cancer survivorship was grounded in the recommendations from the Institute of Medicine report from 2006. As a means of refining our CSE curriculum, we introduced Evidence Table (ET) development. ETs are formatted summaries of methods, data, and outcomes from related studies used to answer specific questions. ETs facilitate the development of recommendations and standards of care. ET development was proposed to enhance the CSE experience allowing trainees to: 1) understand data supporting survivorship recommendations, 2) practice grading the evidence, 3) become more critical in appraisal of published studies, and 4) discover areas where further research is needed to substantiate cancer survivorship care plans. Methods: A total of 19 trainees participated in academic year 2013-2014 and 18 trainees in 2014-2015. Trainees were required to define key questions pertaining to survivorship, probe the literature for available data addressing these questions, and develop ETs in which the evidence was then graded. To ascertain the value of this experience from the trainees’ perspectives, anonymous and voluntary pre- and post-Workshop surveys were administered. The course was modified after the first academic year based on results of a trainee feed-back. Results: Following course modification in 2014-2015, 92% of trainees responded that they used some of the learned course information in their clinics. This represents significant improvement from 45% the previous year (p = 0.02). Significant improvement was observed (from 18% to 67%) in the perception that the course influenced trainees' approach to the medical literature. Ninety-two percent responded that they learned more about survivorship as a result of the CSE Workshop. All trainees reported that, to some extent, CSE has helped to make them better oncologists. Conclusions: ET development is a feasible, meaningful, and novel approach to fostering independent learning in cancer survivorship.

The evolving role of radiotherapy in treatment of oligometastatic NSCLC

Non-small cell lung cancer (NSCLC) patients with metastases limited in site and number, termed oligometastases, may represent a unique subpopulation of advanced NSCLC with improved prognosis. The optimal management of these patients remains unclear with the treatment approach currently undergoing a paradigm shift. The potential benefit of aggressive metastasis directed local treatment with surgery and/or radiotherapy (RT) in combination with systemic therapy is bolstered predominantly by retrospective analyses but also by a growing number of non-randomized prospective studies regarding the use of ablative RT techniques including stereotactic body radiotherapy (SBRT), alternatively termed stereotactic ablative radiotherapy (SABR), directed at the primary tumor (if present) and all metastatic sites. Long-term survival is possible in a subset of patients treated aggressively in this manner. The challenge for the clinical oncology community moving forward is appropriately selecting patients for this treatment approach based on clinical, imaging, and molecular features and increasing enrollment of patients to prospective clinical trials to more definitively determine the added benefit and appropriate timing of aggressive metastasis directed therapy in the oligometastatic setting.

Cardiovascular Disease Mortality After Chemotherapy or Surgery for Testicular Nonseminoma: A Population-Based Study

PURPOSE

Increased risks of incident cardiovascular disease (CVD) in patients with testicular cancer (TC) given chemotherapy in European studies were largely restricted to long-term survivors and included patients from the 1960s. Few population-based investigations have quantified CVD mortality during, shortly after, and for two decades after TC diagnosis in the era of cisplatin-based chemotherapy.

PATIENTS AND METHODS

Standardized mortality ratios (SMRs) for CVD and absolute excess risks (AERs; number of excess deaths per 10,000 person-years) were calculated for 15,006 patients with testicular nonseminoma reported to the population-based Surveillance, Epidemiology, and End Results program (1980 to 2010) who initially received chemotherapy (n=6,909) or surgery (n=8,097) without radiotherapy and accrued 60,065 and 81,227 person-years of follow-up, respectively. Multivariable modeling evaluated effects of age, treatment, extent of disease, and other factors on CVD mortality.

RESULTS

Significantly increased CVD mortality occurred after chemotherapy (SMR, 1.36; 95% CI, 1.03 to 1.78; n=54) but not surgery (SMR, 0.81; 95% CI, 0.60 to 1.07; n=50). Significant excess deaths after chemotherapy were restricted to the first year after TC diagnosis (SMR, 5.31; AER, 13.90; n=11) and included cerebrovascular disease (SMR, 21.72; AER, 7.43; n=5) and heart disease (SMR, 3.45; AER, 6.64; n=6). In multivariable analyses, increased CVD mortality after chemotherapy was confined to the first year after TC diagnosis (hazard ratio, 4.86; 95% CI, 1.25 to 32.08); distant disease (P<.05) and older age at diagnosis (P<.01) were independent risk factors.

CONCLUSION

This is the first population-based study, to our knowledge, to quantify short- and long-term CVD mortality after TC diagnosis. The increased short-term risk of CVD deaths should be further explored in analytic studies that enumerate incident events and can serve to develop comprehensive evidence-based approaches for risk stratification and application of preventive and interventional efforts.

Second primary head and neck cancer after Hodgkin lymphoma: a population-based study of 44,879 survivors of Hodgkin lymphoma

BACKGROUND

Survivors of Hodgkin lymphoma (HL) are at an increased risk of developing second malignancies. To the authors' knowledge, the risks of head and neck cancer (HNC) after HL and subsequent survival have not been thoroughly investigated.

METHODS

From the US population-based Surveillance, Epidemiology, and End Results (SEER) database for 1973 through 2011, survivors of HL who developed HNC as a second cancer were analyzed. Patients with a first primary HNC were used as a comparison group. Observed-to-expected ratios and summary statistics were performed on patients with HL with squamous cell carcinoma (HL-SCC) and salivary gland cancer (HL-SGC). The impact of HL history on overall survival was assessed using a multivariate Cox proportional hazards model.

RESULTS

The observed-to-expected ratio for SCC among patients with HL was 1.73 (95% confidence interval [95% CI], 1.36-2.16; P<.05), whereas it was 8.56 for SGC (95% CI, 5.82-12.15; P<.05). Using Cox proportional hazards modeling, a history of HL was found to be an adverse prognostic factor for overall survival for SCC (hazard ratio, 1.37; 95% CI, 1.08-1.73 [P = .009]) but not SGC (hazard ratio, 1.21; 95% CI, 0.82-1.79 [P = .34]). The inferior survival of the patients in the HL-SCC cohort appears to be attributable to more deaths from HL and other malignancies diagnosed after SCC.

CONCLUSIONS

There is a significantly increased risk of salivary and nonsalivary HNC after HL, and worse survival for patients with HL-SCC versus those with a first primary SCC. Clinicians should be aware of the risks of HNC after HL. In the absence of evidence-based criteria, the authors recommend that survivors of HL undergo periodic head and neck examination.

Radical irradiation of extracranial oligometastases

Advances in radiotherapy planning and delivery have been used to treat patients with limited metastatic disease. With these techniques, high rates of treated metastasis control and low toxicity have been reported. Some patients have long disease-free intervals after radiotherapy similar to those seen after surgical resection. Ongoing studies will determine the benefit of these irradiation techniques to treat limited metastases, identify appropriate candidates, and assist in integrating these treatments into management strategies for specific diseases.

Spinal drop metastasis in myxopapillary ependymoma: a case report and a review of treatment options

Myxopapillary ependymoma (MPE) is a World Health Organization grade I ependymoma that is quite rare and generally thought to be benign. Possible drop metastasis from MPE has been reported three times in the literature; in each case there were cotemporaneous additional MPE lesions. We report the case of a man who had a piecemeal gross total resection of a MPE at L1-L3 followed by adjuvant external beam radiotherapy (EBRT) who presented sixteen months later with a lesion in the thecal sac consistent with drop metastasis. A subtotal resection and adjuvant EBRT were performed. The patient has been disease-free in follow-up 27 months from the second surgery. A review of the literature regarding the treatment for MPE showed that gross total resection is optimal initial management. Several retrospective studies supported the role of adjuvant radiotherapy in enhancing local control and progression-free survival. Chemotherapy has a minimal role in the management of MPE.

An individual patient data metaanalysis of outcomes and prognostic factors after treatment of oligometastatic non-small-cell lung cancer

INTRODUCTION/BACKGROUND

An individual patient data metaanalysis was performed to determine clinical outcomes, and to propose a risk stratification system, related to the comprehensive treatment of patients with oligometastatic NSCLC.

MATERIALS AND METHODS

After a systematic review of the literature, data were obtained on 757 NSCLC patients with 1 to 5 synchronous or metachronous metastases treated with surgical metastectomy, stereotactic radiotherapy/radiosurgery, or radical external-beam radiotherapy, and curative treatment of the primary lung cancer, from hospitals worldwide. Factors predictive of overall survival (OS) and progression-free survival were evaluated using Cox regression. Risk groups were defined using recursive partitioning analysis (RPA). Analyses were conducted on training and validating sets (two-thirds and one-third of patients, respectively).

RESULTS

Median OS was 26 months, 1-year OS 70.2%, and 5-year OS 29.4%. Surgery was the most commonly used treatment for the primary tumor (635 patients [83.9%]) and metastases (339 patients [62.3%]). Factors predictive of OS were: synchronous versus metachronous metastases (P < .001), N-stage (P = .002), and adenocarcinoma histology (P = .036); the model remained predictive in the validation set (c-statistic = 0.682). In RPA, 3 risk groups were identified: low-risk, metachronous metastases (5-year OS, 47.8%); intermediate risk, synchronous metastases and N0 disease (5-year OS, 36.2%); and high risk, synchronous metastases and N1/N2 disease (5-year OS, 13.8%).

CONCLUSION

Significant OS differences were observed in oligometastatic patients stratified according to type of metastatic presentation, and N status. Long-term survival is common in selected patients with metachronous oligometastases. We propose this risk classification scheme be used in guiding selection of patients for clinical trials of ablative treatment.

Local control rates with five-fraction stereotactic body radiotherapy for oligometastatic cancer to the lung

OBJECTIVE

To report our institutional experience with five fractions of daily 8-12 Gy stereotactic body radiotherapy (SBRT) for the treatment of oligometastatic cancer to the lung.

METHODS

Thirty-four consecutive patients with oligometastatic cancers to the lung were treated with image-guided SBRT between 2008 and 2011. Patient age ranged from 38 to 81 years. There were 17 males and 17 females. Lung metastases were from the following primary cancer types: colon cancer (n=13 patients), head and neck cancer (n=6), breast cancer (n=4), melanoma (n=4), sarcoma (n=4) and renal cell carcinoma (n=3). The median prescription dose was 50 Gy in five fractions (range, 40-60 Gy) to the isocenter, with the 80% isodose line encompassing the planning target volume (PTV) [defined as gross tumor volume (GTV) + 7-11 mm volumetric expansion]. The follow-up interval ranged from 2.4-54 months, with a median of 16.7 months.

RESULTS

The 1-, 2-, and 3-year patient local control (LC) rates for all patients were 93%, 88%, and 80% respectively. The 1-, 2-, and 3-year overall survival (OS) rates were 62%, 44%, and 23% respectively. The 1- and 2-year patient LC rates were 95% and 88% for tumor size 1-2 cm (n=25), and 86% for tumor size 2-3 cm (n=7). The majority (n=4) of local failures occurred within 12 months. No patient experienced local failure after 12 months except for one patient with colon cancer whose tumors progressed locally at 26 months. All five patients with local recurrences had colorectal cancer. Statistical analyses showed that age, gender, previous chemotherapy, previous surgery or radiation had no significant effect on LC rates. No patient was reported to have any symptomatic pneumonitis at any time point.

CONCLUSIONS

SBRT for oligometastatic disease to the lung using 8-12 Gy daily fractions over five treatments resulted in excellent 1- and 2-year LC rates. Most local failures occurred within the first 12 months, with five local failures associated with colorectal cancer. The treatment is safe using this radiation fractionation schedule with no therapy-related pneumonitis.

Age and Racial Differences among PSA-Detected (AJCC Stage T1cN0M0) Prostate Cancer in the U.S.: A Population-Based Study of 70,345 Men

Purpose: Few studies have evaluated the risk profile of prostate-specific antigen (PSA)-detected T1cN0M0 prostate cancer, defined as tumors diagnosed by needle biopsy because of elevated PSA levels without other clinical signs of disease. However, some men with stage T1cN0M0 prostate cancer may have high-risk disease (HRD), thus experiencing inferior outcomes as predicted by a risk group stratification model.

Methods: We identified men diagnosed with stage T1cN0M0 prostate cancer from 2004 to 2008 reported to the surveillance, epidemiology, and end results (SEER) program. Multivariate logistic regression was used to model the probability of intermediate-risk-disease (IRD) (PSA ≥ 10 ng/ml but <20 ng/ml and/or GS 7), and high-risk-disease (HDR) (PSA ≥ 20 ng/ml, and/or GS ≥ 8), relative to low-risk disease (LRD) (PSA < 10 ng/ml and GS ≤ 6), adjusting for age, race, marital status, median household income, and area of residence.

Results: A total of 70,345 men with PSA-detected T1cN0M0 prostate cancer were identified. Of these, 47.6, 35.9, and 16.5% presented with low-, intermediate-, and high-risk disease, respectively. At baseline (50 years of age), risk was higher for black men than for whites for HRD (OR 3.31, 95% CI 2.85–3.84). The ORs for age (per year) for HRD relative to LRD were 1.09 (95% CI 1.09–1.10) for white men, and as 1.06 (95% CI 1.05–1.07) for black men. Further, among a subgroup of men with low PSA (<10 ng/ml) T1cN0M0 prostate cancer, risk was also higher for black man than for white men at baseline (50 years of age) (OR 2.70, 95% CI 2.09–3.48). The ORs for age (per year) for HRD relative to LRD were 1.09 (95% CI 1.09–1.10) for white men, and as 1.06 (95% CI 1.05–1.07) for black men.

Conclusion: A substantial proportion of men with PSA-detected prostate cancer as reported to the SEER program had HRD. Black race and older age were associated with a greater likelihood of HRD.

Correlation between progression free survival and dynamic susceptibility contrast MRI perfusion in WHO grade III glioma subtypes

The purpose of this study was to determine whether dynamic susceptibility contrast MR perfusion relative cerebral blood volume (rCBV) correlates with prognosis of World Health Organization (WHO) grade III glial tumors and their different subtypes. Retrospective evaluation of pre-treatment tumor rCBV derived from dynamic susceptibility contrast MR perfusion was performed in 34 patients with histopathologically diagnosed WHO grade III glial tumors (anaplastic astrocytomas (n = 20), oligodendrogliomas (n = 4), and oligoastrocytomas (n = 10)). Progression free survival was correlated with rCBV using Spearman rank analysis. ROC curve analysis was performed to determine the operating point for rCBV in patients with anaplastic astrocytomas dichotomized at the median progression free survival time. For all grade III tumors (n = 34) the mean rCBV was 2.51 with a progression free survival of 705.5 days. The mean rCBV of anaplastic astrocytomas was 2.47 with progression free survival 495.2 days. In contrast, the mean rCBV for oligodendroglial tumors was 2.56 with a progression free survival of 1005.6 days. Although there was no significant correlation between rCBV and progression free survival among all types of grade III gliomas (P = 0.12), among anaplastic astrocytomas there was a significant correlation between pretreatment rCBV and progression free survival with correlation coefficient of -0.51 (P = 0.02). The operating point for rCBV in patients with anaplastic astrocytomas dichotomized at the median progression free survival time (446.5 days) was 2.86 with 78 % accuracy and there was a significant difference between the survival of patients with anaplastic astrocytomas in the dichotomized groups (P = 0.0009). Pre-treatment rCBV may serve as a prognostic imaging biomarker for anaplastic astrocytomas, but not grade III oligodendroglioma tumors.

Multicentre results of stereotactic body radiotherapy for secondary liver tumours

BACKGROUND

Surgical resection is the standard treatment for liver metastases, although for the majority of patients this is not possible. Stereotactic body radiotherapy (SBRT) is an alternative local-regional therapy. The purpose of this study was to evaluate the results of SBRT for secondary liver tumours from a combined multicentre database.

METHODS

Variables from patients treated with SBRT from four Academic Medical Centres were entered into a common database. Local tumour control and 1-year survival rates were calculated.

RESULTS

In total, 153 patients (91 women) 59 ± 8.4 years old with 363 metastatic liver lesions were treated with SBRT. The underlying primary tumour arose from gastrointestinal (GI), retroperitoneal and from extra-abdominal primaries in 56%, 8% and 36% of patients, respectively. Metastases, with a gross tumour volume (GTV) of 138.5 ± 126.8 cm(3) , were treated with a total radiation dose of 37.5 ± 8.2 Gy in 5 ± 3 fractions. The 1-year overall survival was 51% with an overall local control rate of 62% at a mean follow-up of 25.2 ± 5.9 months. A complete tumour response was observed in 32% of patients. Grade 3-5 adverse events were noted in 3% of patients.

CONCLUSION

Secondary liver tumours treated with SBRT had a high rate of local control with a low incidence of adverse events.

Solid tumors after chemotherapy or surgery for testicular nonseminoma: a population-based study

PURPOSE

Increased risks of solid tumors after older radiotherapy strategies for testicular cancer (TC) are well established. Few population-based studies, however, focus on solid cancer risk among survivors of TC managed with nonradiotherapy approaches. We quantified the site-specific risk of solid cancers among testicular nonseminoma patients treated in the modern era of cisplatin-based chemotherapy, without radiotherapy.

PATIENTS AND METHODS

Standardized incidence ratios (SIRs) for solid tumors were calculated for 12,691 patients with testicular nonseminoma reported to the population-based Surveillance, Epidemiology, and End Results program (1980 to 2008) and treated initially with either chemotherapy (n = 6,013) or surgery (n = 6,678) without radiotherapy. Patients accrued 116,073 person-years of follow-up.

RESULTS

Two hundred ten second solid cancers were observed. No increased risk followed surgery alone (SIR, 0.93; 95% CI, 0.76 to 1.14; n = 99 solid cancers), whereas significantly increased 40% excesses (SIR, 1.43; 95% CI, 1.18 to 1.73; n = 111 solid cancers) occurred after chemotherapy. Increased risks of solid cancers after chemotherapy were observed in most follow-up periods (median latency, 12.5 years), including more than 20 years after treatment (SIR, 1.54; 95% CI, 0.96 to 2.33); significantly increased three- to seven-fold risks occurred for cancers of the kidney (SIR, 3.37; 95% CI, 1.79 to 5.77), thyroid (SIR, 4.40; 95% CI, 2.19 to 7.88), and soft tissue (SIR, 7.49; 95% CI, 3.59 to 13.78).

CONCLUSION

To our knowledge, this is the first large population-based series reporting significantly increased risks of solid cancers among patients with testicular nonseminoma treated in the modern era of cisplatin-based chemotherapy. Subsequent analytic studies should focus on the evaluation of dose-response relationships, types of solid cancers, latency patterns, and interactions with other possible factors, including genetic susceptibility.

The integration of cancer survivorship training in the curriculum of hematology/oncology fellows and radiation oncology residents

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Background: The population of cancer survivors is steadily increasing. Cancer specialists require an understanding of survivors’ needs to insure optimal delivery of post-treatment care. Residency and fellowship training traditionally focus on cancer therapy, while survivorship care is often not emphasized. As a paradigm shift in our training programs, we instituted a Cancer Survivorship Workshop. Methods: In academic year 2011-2012 a Cancer Survivorship Workshop course was held at the James P. Wilmot Cancer Center/University of Rochester, a comprehensive cancer center with accredited training programs in Hematology Oncology (HO) and Radiation Oncology (RO). Course objectives included 1) learning about survivorship from patient, primary care physician, and oncologist perspectives using an evidenced-based curriculum; 2) designing treatment summaries (TS) and survivorship care plans (SCP) for 5 malignancies (lung, breast, prostate, colon, lymphoma) for integration into the electronic medical record and dissemination to patients; 3) establishing collaboration between HO and RO trainees by working together in assigned teams. Course impact was assessed pre- and post- training with a 13 question survey. Questions were answered using a 10 point scale, with a pre-defined rating system for each question. Results: Significant differences in responses to several survey questions were observed comparing pre- and post-course experience. Improvement in comfort level when discussing survivorship issues with patients (median pre-course score=6, post-course=8; p=.001), reported knowledge of survivorship care for 5 types of cancer (5 to 7; p=.002), confidence in ability to explain a SCP to a patient (5 to 8; p=.001), and comfort discussing late effects of treatment with patients (5 to 8; p=.001). The number of articles read regarding cancer survivorship increased. Five unique sets of TS and SCP’s were completed. Conclusions: This study demonstrates the feasibility of implementing cancer survivorship education into the curriculum of HO and RO training. This represents, to our knowledge, the first documented educational undertaking of its kind nationally in HO and RO Programs.

PSA-detected prostate cancer in the United States: A population-based study of 70,345 men with AJCC stage T1cN0M0 disease

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Background: The U.S. Preventive Services Task Force (USPSTF) recently recommended against prostate-specific antigen (PSA)-based screening for prostate cancer. This recommendation has heightened the debate about risks and benefits of prostate cancer screening, and underscored our limited understanding of PSA-detected prostate cancer. The purpose of this study was to determine the frequency of various risks of prostate cancer based on patient characteristics and PSA levels. Methods: This population-based study used the Surveillance, Epidemiology, and End Results (SEER) program to identify men with AJCC stage T1cN0M0 disease diagnosed between 1/2004 and 12/2008. Multivariate logistic regression was conducted to model the probability of developing low (PSA <10 mg/L and Gleason score ≤6), intermediate (PSA between 10 mg/L to 20 mg/L and/or Gleason score 7), and high risk diseases (PSA ≥20 mg/L, and/or Gleason score ≥8). Results: A total of 70,345 men with PSA-detected T1cN0M0 prostate cancer were evaluated. Among them, 47.6%, 35.9% and16.5% had low, intermediate, or high risk disease, respectively. Odds ratios (OR) of having intermediate or high risk disease in patients ≥75 years old were 4.47 (95% confidence interval (CI) 3.81 to 5.26, p<0.01) and 9.39 (95% CI 7.25 to 12.16, p<0.01), respectively, when compared with patients aged <50. Also, black men had increased ORs for intermediate and high risk disease compared with white men (OR 1.50, 95% CI 1.42 to 1.58, p<0.01 for intermediate risk disease; OR 1.84, 95% CI 1.72 to 19.97, p<0.01 for high risk disease). While men aged >75 accounted for 11.8% of the population at risk, they accounted for 24.3% of intermediate and 26.1% of high risk disease. Conclusions: A substantial number of PSA-detected prostate cancer patients have either intermediate or high risk disease at diagnosis. Men age >75 or of black race have the highest risk of presenting with intermediate or high risk disease.

Thoracic malignant solitary fibrous tumors: A population-based study of survival

INTRODUCTION

This study characterizes the overall survival (OS) and cause specific survival (CSS) of patients with thoracic malignant solitary fibrous tumors.

METHODS

Eighty-two patients with malignant solitary fibrous tumors of the lung, pleura or mediastinum, diagnosed from 2001-2007, were retrospectively analyzed using the population-based Surveillance, Epidemiology, and End Results database.

RESULTS

Among 77 patients with available staging information, 42% (n=32) had localized disease, 31% (n=24) had regional disease extension (without nodal involvement) and 27% had regional-nodal (n=2) or distant (n=19) metastases. Cancer-directed surgery was performed in 85%; radiation was performed in 16%. The 1-year, 5-year and median OS were 87%, 49% and 4.6 years respectively. The 1-year, 5-year and median CSS were 89%, 61% and 5.7 years respectively. Less advanced stage and undergoing cancer-directed surgery were favorable prognostic factors. For localized, regional and distant stage the median OS was: not reached at 6.3 years, 4.4 years and 2.0 years respectively (P=0.021); the median CSS was not reached at 6.3 years, 5.0 years and 2.4 years (P=0.068). For patients undergoing versus not undergoing surgery, the median OS was 4.9 vs 0.9 years (P=0.053) and median CSS was 5.7 vs 0.9 years (P=0.011). Tumor size was not significant.

CONCLUSIONS

From a population-based analysis of patients with thoracic malignant solitary fibrous tumors, stage and cancer-directed surgery had the greatest impact on OS and CSS. While being amenable to surgery likely reflects more indolent disease and/or better performance status and cardiopulmonary function, the significantly favorable impact of surgery also likely reflects a therapeutic benefit.

Variables affecting survival after second primary lung cancer: A population-based study of 187 Hodgkin's lymphoma patients

BACKGROUND

Patients successfully treated for Hodgkin's lymphoma (HL) are at known risk for subsequent malignancies, the most common of which is lung cancer. To date, no population-based study has analyzed prognostic variables for overall survival (OS) among HL survivors who developed non-small cell lung cancer (NSCLC).

METHODS

For 187 HL patients who developed NSCLC (among 22,648 HL survivors), we examined the impact of the following variables on OS after NSCLC diagnosis: gender, race, sociodemographic status (based upon county of residence), calendar year and age at NSCLC diagnosis, NSCLC histology and grade, HL stage and subtype, radiation for HL and latency between HL and NSCLC. Patients were grouped by NSCLC stage as follows: localized, regional or distant. All patients were reported to the population-based Surveillance, Epidemiology, and End Results program. For those variables significant on univariate analyses, hazard ratios (HR) were derived from Cox proportional hazards model.

RESULTS

Sociodemogaphic status, gender and latency between NSCLC and HL did not significantly affect OS of any NSCLC stage group. For patients with localized NSCLC, a history of mixed celluarlity HL was associated with a 3-fold improved OS (P=0.006). For patients with regional NSCLC, prior radiotherapy for HL was associated with a 2-fold worse OS (P=0.025).

CONCLUSIONS

A history of mixed cellularity HL subtype and a history of no radiotherapy for HL are favorable prognostic factors among patients who develop NSCLC. Further research into clinicopathologic and treatment-associated variables potentially affecting OS after second primary NSCLC among HL survivors is warranted.

Long-term survival among Hodgkin's lymphoma patients with gastrointestinal cancer: a population-based study

BACKGROUND

The increased risk of gastrointestinal (GI) cancers after Hodgkin's lymphoma (HL) is well established. However, no large population-based study has described the actuarial survival after subsequent GI cancers in HL survivors (HL-GI).

PATIENTS AND METHODS

For 209 patients with HL-GI cancers (105 colon, 35 stomach, 30 pancreas, 21 rectum, and 18 esophagus) and 484 165 patients with first primary GI cancers (GI-1), actuarial survival was compared, accounting for age, gender, race, GI cancer stage, radiation for HL, and other variables.

RESULTS

Though survival of HL patients who developed localized stage colon cancer was similar to that of the GI-1 group, overall survival (OS) of HL patients with regional or distant stage colon cancer was reduced [hazard ratio, (HR)=1.46, P=0.01]. The HL survivors with regional or distant stage colon cancer in the transverse segment had an especially high risk of mortality (HR: 2.7, P=0.001 for OS). For localized stomach cancer, OS was inferior among HL survivors (HR=3.46, P=0.006).

CONCLUSIONS

The HL patients who develop GI cancer experience significantly reduced survival compared with patients with a first primary GI cancer. Further research is needed to explain the inferior survival of HL patients and to define selection criteria for cancer screening in HL survivors.

Second malignant neoplasms (SMN) among 18,627 testicular cancer survivors (TCS) after chemotherapy (CHEM) or surgery (SURG)

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Background: Increased risks of SMN after radiotherapy (RT) for testicular cancer (TC) are well established. Few population-based studies, however, have focused on SMN risk among a contemporary group of TCS managed initially with non-RT approaches, including CHEM. Methods: Standardized incidence ratios (SIR) of SMN stratified by site and time since TC diagnosis were calculated for 18,627 TCS reported to the SEER program (1980-2008) who initially had CHEM (n=8,058) or SURG (n=10,569) alone without RT, with each cohort accruing 65,398 and 92,681 person-years (PY) of follow-up respectively. Results: After CHEM, significantly increased risks of solid cancers (n=154; SIR 1.3; 95% CI 1.1-1.5; absolute excess risk (AER) 5.4 per 10,000 PY) and leukemias (n=18, SIR 3.9; 95% CI 2.3-6.1; AER 2.0) were observed. Solid cancer risk remained elevated for > 20 yrs, whereas excess leukemias were concentrated within 10 years after diagnosis. SIRs for solid cancers during the <1, 1-4, 5-9, 10-14, 15-19, and 20+ yr periods were 2.0 (95% CI 1.03-3.5), 1.4 (95% CI 0.97-2.0), 0.8 (95% CI 0.5-1.2), 1.3 (95% CI 0.9-1.8), 1.6 (95% CI 1.05-2.2), and 1.5 (95% CI 0.95-2.2) respectively (P-trend 0.5) whereas SIRs for leukemia were 3.2, 9.9 (P<0.05), 2.6, and 2.3 respectively, with no cases reported in the latter 2 intervals. Median latencies to the development of solid cancers and leukemia were 12.5 yr (0.1-28) and 2.5 yr (0.1-14) respectively. Increased site-specific risks were apparent for cancers of liver (SIR 1.9; 95% CI 0.6-4.4); pancreas (SIR 2.1; 95% CI 0.8-4.6); soft tissue (SIR 4.9; 95% CI 2.1-9.7); bladder (SIR 1.9; 95% CI 1.02-3.3); kidney (SIR 2.6; 95% CI 1.4-4.3); brain/CNS (SIR 1.8; 95% CI 0.7-3.7), and thyroid (SIR 3.9; 95% CI 2.1-6.6). Secondary leukemias included 16 non-lymphocytic and 2 lymphocytic leukemias. In contrast, among TCS managed initially with SURG alone, no excess solid cancers were observed (n=198; SIR 1.0; 95% CI 0.8-1.1), albeit an increased risk of leukemia (n=15; SIR 1.9; 95% CI 1.1-3.2, AER 0.8) was seen. Conclusions: Future analytic studies should further evaluate the site-specific risks of SMN after modern CHEM for TC and the baseline risk among patients managed with non-cytotoxic approaches.

Second primary lung cancer after head and neck squamous cell cancer: population-based study of risk factors

BACKGROUND

Patients with head and neck squamous cell cancer (HNSCC) are at risk of developing second primary lung cancer (SPLC).

METHODS

Among 61,883 patients with HNSCC from the Surveillance, Epidemiology and End Results (SEER) database, 4522 developed SPLC (any histology) ≥2 months after HNSCC. We correlated risk with demographic and tumor-related parameters.

RESULTS

The risk of SPLC after HNSCC was 5.8%, 11.4%, and 16.4% at 5, 10, and 15 years, respectively. From Cox regression, significantly adverse (p < .0001) risk factors for SPLC included: regional versus localized HNSCC stage (hazard ratio [HR] = 1.16), hypopharyngeal or supraglottic laryngeal site (HR = 1.57), increased age (HR = 1.26/decade), black race (HR = 1.27), and male sex (HR = 1.26). Glottic (HR = 0.75) and tonsillar or oral cavity sites (HR = 0.80) were associated with significantly (p < .0001) lower risks of SPLC.

CONCLUSION

From population-based actuarial analyses, HNSCCs with more aggressive clinicopathologic features were more apt to develop SPLC, suggestive of similar environmental and/or host factors for these cancers.

Incidental brain lesions in children: to treat or not to treat?

Central nervous system (CNS) lesions that are discovered incidentally when imaging children for problems that were unrelated to the detected lesion pose a dilemma to physicians. Because there are few data on the outcome of such cases, we retrospectively reviewed the clinical course of a group of children followed at our institution with brain lesions found incidentally on neuro-imaging. A database of all children with brain lesions followed at the University of Rochester medical center from 2000 to 2010 was reviewed. Data were obtained regarding presentation, magnetic resonance imaging (MRI) features, treatment, progression-free survival, and overall survival of children with brain lesions found incidentally. Of the 244 children with brain lesions seen over this time period, 21 (8.6%) were found to have incidentally discovered brain lesions. Of these 21 children, 12 (57%) underwent surgical resection of their brain lesions. Ten patients (48%) had symptoms considered to be unassociated with the detected lesion. Lesions were found in the cerebellum (n = 7, 33%), midline (n = 5, 24%), and cerebrum (n = 9, 43%). All lesions were ≤5 cm in diameter. Eight patients (38%) had surgery at presentation, one because of imaging features suspicious for a posterior fossae ependymoma, and the seven others because of location in the posterior fossae or brain stem. Of the remaining 13 patients, five had progression of disease on serial MRI scans: four underwent surgery and the fifth was monitored and remained stable after the initial progression stabilized. Nine of the ten patients (90%) with posterior fossae lesions underwent surgery, while only three of 11 with supratentorial lesions underwent surgery (27%) (P = 0.006). The progression free survival was 94% at 12 months (95% CI 65-99%) and 71% at 24 months (95% CI 39-88%). At a median follow-up of 32 months, the overall survival was 100%. Incidentally detected CNS lesions are usually small. The outcome for children with such lesions is excellent. Close monitoring of these patients with serial MRIs may be a safe alternative to immediate biopsy and/or resection for select patients.

Spurious progression in pediatric brain tumors

In this study, we sought to characterize post-therapy MRI changes mimicking progression, which we refer to as "spurious progression" (SP) in children with brain tumors. We analyzed whether SP is associated with particular tumor types or therapeutic modalities. Between 2000 and 2009, we identified 181 consecutive children <21 years of age at our center who were treated for brain tumors and had at least three MRI scans within a year after completing therapy. SP was defined as MRI abnormalities characterized by increase in size, enhancement, edema, or cystic changes within 12 months following therapy, and stabilization or improvement on subsequent imaging. One-hundred forty-one patients with brain tumors were evaluable. Fifty-six (40%) had imaging abnormalities initially suggestive of disease progression; of these, 34 (24%) had true disease progression (TP). The remaining 22 (16%) had SP based on either stability, decrease in enhancement, edema, size, or disappearance of these cystic or non-cystic abnormalities. SP occurred in patients with low grade (n = 20) and high grade lesions (n = 2). Median time to SP was 2.4 months (range, 0.7-8.3 months), with time to stability, decrease, or disappearance at a median of 4 months (range 1.4-7.7 months). Five patients were clinically symptomatic from SP and were treated with steroids, cyst drainage, and/or surgery. Therefore, SP occurs more commonly in children with low grade tumors, but can also occur with high grade brain tumors, regardless of therapeutic approach.

Oligometastases treated with stereotactic body radiotherapy: long-term follow-up of prospective study

PURPOSE

To analyze the long-term survival and tumor control outcomes after stereotactic body radiotherapy (SBRT) for metastases limited in number and extent.

METHODS AND MATERIALS

We prospectively analyzed the long-term overall survival (OS) and cancer control outcomes of 121 patients with five or fewer clinically detectable metastases, from any primary site, metastatic to one to three organ sites, and treated with SBRT. Freedom from widespread distant metastasis (FFDM) was defined as metastatic disease not amenable to local therapy (i.e., resection or SBRT). Prognostic variables were assessed using log-rank and Cox regression analyses.

RESULTS

For breast cancer patients, the median follow-up was 4.5 years (7.1 years for 16 of 39 patients alive at the last follow-up visit). The 2-year OS, FFDM, and local control (LC) rate was 74%, 52%, and 87%, respectively. The 6-year OS, FFDM, and LC rate was 47%, 36%, and 87%, respectively. From the multivariate analyses, the variables of bone metastases (p = .057) and one vs. more than one metastasis (p = .055) were associated with a fourfold and threefold reduced hazard of death, respectively. None of the 17 bone lesions from breast cancer recurred after SBRT vs. 10 of 68 lesions from other organs that recurred (p = .095). For patients with nonbreast cancers, the median follow-up was 1.7 years (7.3 years for 7 of 82 patients alive at the last follow-up visit). The 2-year OS, FFDM, and LC rate was 39%, 28%, and 74%, respectively. The 6-year OS, FFDM, and LC rate was 9%, 13%, and 65%, respectively. For nonbreast cancers, a greater SBRT target volume was significantly adverse for OS (p = .012) and lesion LC (p < .0001). Patients whose metastatic lesions, before SBRT, demonstrated radiographic progression after systemic therapy experienced significantly worse OS compared with patients with stable or regressing disease.

CONCLUSIONS

Select patients with limited metastases treated with SBRT are long-term survivors. Future research should address the therapeutic benefit of SBRT for these patients.

Comparison of outcomes in patients with stage III versus limited stage IV non-small cell lung cancer

BACKGROUND

Standard therapy for metastatic non small cell lung cancer (NSCLC) includes palliative systemic chemotherapy and/or radiotherapy. Recent studies of patients with limited metastases treated with curative-intent stereotactic body radiation therapy (SBRT) have shown encouraging survival. We hypothesized that patients treated with SBRT for limited metastases have comparable outcomes with those treated with curative-intent radiation for Stage III NSCLC.

METHODS

We retrospectively reviewed the records of NSCLC patients treated with curative-intent radiotherapy at the University of Rochester from 2000-2008. We identified 3 groups of patients with NSCLC: stage III, stage IV, and recurrent stage IV (initial stage I-II). All stage IV NSCLC patients treated with SBRT had ≤ 8 lesions.

RESULTS

Of 146 patients, 88% had KPS ≥ 80%, 30% had > 5% weight loss, and 95% were smokers. The 5-year OS from date of NSCLC diagnosis for stage III, initial stage IV and recurrent stage IV was 7%, 14%, and 27% respectively. The 5-year OS from date of metastatic diagnosis was significantly (p < 0.00001) superior among those with limited metastases (≤ 8 lesions) versus stage III patients who developed extensive metastases not amenable to SBRT (14% vs. 0%).

CONCLUSION

Stage IV NSCLC is a heterogeneous patient population, with a selected cohort apparently faring better than Stage III patients. Though patients with limited metastases are favorably selected by virtue of more indolent disease and/or less bulky disease burden, perhaps staging these patients differently is appropriate for prognostic and treatment characterization. Aggressive local therapy may be indicated in these patients, though prospective clinical studies are needed.

Survival after second primary lung cancer: a population-based study of 187 Hodgkin lymphoma patients

BACKGROUND

Lung cancer accounts for the largest absolute risk of second malignancies among Hodgkin lymphoma (HL) survivors. However, no population-based studies have compared overall survival (OS) between HL survivors who developed nonsmall cell lung cancer (HL-NSCLC) versus patients with first primary NSCLC (NSCLC-1).

METHODS

The authors compared the OS of 178,431 patients who had NSCLC-1 and 187 patients who had HL-NSCLC (among 22,648 HL survivors), accounting for sex, race, sociodemographic status, calendar year, and age at NSCLC diagnosis, and NSCLC histology and stage. All patients were reported to the population-based Surveillance, Epidemiology, and End Results Program. Hazard ratios (HRs) were derived from a Cox proportional hazards model.

RESULTS

Although the NSCLC stage distribution was similar in both groups (20% localized, 30% regional, and 50% distant), HL survivors experienced significantly inferior stage-specific OS. For patients with localized, regional, and distant stage NSCLC, the HRs (95% confidence interval [CI]) for death among HL survivors were 1.60 (95% CI, 1.08-2.37; P < .0001), 1.67 (95% CI, 1.26-2.22; P = .0004), and 1.31 (95% CI, 1.06-1.61; P = .013), respectively. Among HL-NSCLC patients, significant associations were observed between more advanced NSCLC stage and the following variables: younger age at HL diagnosis (P = .003), younger age at NSCLC diagnosis (P = .048), and longer latency between HL and NSCLC diagnoses (P = .015).

CONCLUSIONS

Compared with patients who had de novo NSCLC, HL survivors experienced a significant 30% to 60% decrease in OS after an NSCLC diagnosis. Further research is needed to not only elucidate the clinical-biologic underpinnings of NSCLC after HL, including the influence of previous HL treatment, but also to define the role of lung cancer screening in selected patients.

Stereotactic body radiotherapy for pulmonary metastases from soft-tissue sarcomas: excellent local lesion control and improved patient survival

PURPOSE

Patients with pulmonary metastases (PM) from soft-tissue sarcomas (STS) have historically been treated with surgery and/or chemotherapy. Since 2001, we have treated PM with stereotactic body radiation therapy (SBRT). We postulated that SBRT for PM from STS would yield excellent local control (LC) and overall survival (OS).

METHODS AND MATERIALS

Fifty-two patients with PM from STS, diagnosed between 1990 and 2006 at the University of Rochester, were retrospectively reviewed. Most patients received multimodality treatment comprising of surgery, chemotherapy, and/or radiation. SBRT used the Novalis ExacTrac patient positioning platform, vacuum bag immobilization, and relaxed end-expiratory breath hold techniques.

RESULTS

Leiomyosarcoma (23%), malignant fibrous histiocytoma (19%), and synovial sarcoma (15%) were the most common histologies. Forty-eight percent initially presented with PM, whereas 52% developed PM at a median of 0.7 (0.3-7.3) years after initial diagnosis. Median follow-up from diagnosis of PM was 0.9 (0.3-7.3) years. Fifteen patients underwent SBRT to 74 lesions. Median number of lesions treated was 4 (1-16) per patient and 3.5 (1-6) per session. Preferred dose and fractionation was 50 Gy in 5 Gy fractions. Three-year LC was 82%. No patients experienced Grade ≥ 3 toxicity. Median OS was 2.1 (0.8-11.5) years for patients treated with SBRT, and 0.6 (0.1-7.8) years for those who never received SBRT (p = 0.002).

CONCLUSIONS

SBRT provides excellent LC of PM and may extend OS. SBRT should be considered for all patients with PM from STS, particularly those who are not surgical candidates. Further investigation is warranted to establish criteria for the use of SBRT for STS patients with PM.

Long-term survival among patients with Hodgkin's lymphoma who developed breast cancer: a population-based study

PURPOSE

The increased risk of breast cancer (BC) among women receiving chest radiotherapy for Hodgkin's lymphoma (HL) is well-established. However, there are no large population-based studies that describe overall survival (OS) and cause-specific survival (CSS) compared with women with first primary BC.

METHODS

For 298 HL survivors who developed BC (HL-BC group) and 405,223 women with a first or only BC (BC-1 group), actuarial OS and CSS were compared, accounting for age, BC stage, hormone receptor status, sociodemographic status, radiation for HL, and other variables. All patients were derived from the population-based Surveillance, Epidemiology, and End Results program.

RESULTS

OS among patients with HL-BC was significantly inferior that of to patients with BC-1: 15-year OS was 48% versus 69% (P < .0001) for localized BC, and 33% versus 43% (P < .0001) for regional/distant BC. Patients with HL-BC had a significantly increased seven-fold risk (P < .0001) of death from other cancers (ie, not HL or BC) compared with patients with BC-1. Mortality from heart disease among patients with HL-BC with either localized or regional/distant disease was also significantly increased (hazard ratio = 2.22, P = .04; and hazard ratio = 4.28, P = .02, respectively) compared with patients with BC-1. Although 10-year BC-CSS was similar for patients with HL-BC and BC-1 with regional/distant disease, it was inferior for patients with localized BC (82% v 88%, respectively; P = .002).

CONCLUSION

Women with HL may survive a subsequent diagnosis of BC, only to experience significant excesses of death from other primary cancers and cardiac disease. Greater awareness of screening for cardiac disease and subsequent primary cancers in patients with HL-BC is warranted.

Patterns and timing of recurrence after temozolomide-based chemoradiation for glioblastoma

PURPOSE

To determine recurrence patterns of glioblastoma treated with temozolomide-based chemoradiation.

METHODS

Pretreatment and serial posttreatment magnetic resonance imaging scans of 54 patients were retrospectively evaluated. Central recurrence (i.e., local progression) and the development of new (i.e., interval appearance of discrete enhancing lesion) in-field, marginal, and distant recurrences were assessed, with the pattern of recurrence of individual lesions defined relative to the 95% isodose line (D(95)). Distant recurrences were defined as lesions completely outside D(95), marginal recurrences crossed D(95), and in-field recurrences were completely inside D(95).

RESULTS

At a median follow-up of 17 months, 39 of 54 (72%) patients developed recurrent glioblastoma. Among these 39 patients, central recurrence occurred in 80% (at a median of 7 months from diagnosis); new in-field recurrence developed in 33% (at a median of 14 months); marginal recurrences developed in 15% (at a median of 18 months); and distant recurrences developed in 20% (at a median of 11 months). The actuarial rates of central, new in-field, marginal, distant, and any new recurrences at 1-year were 46%, 15%, 3%, 14%, and 25% respectively, whereas at 2 years, the rates were 68%, 60%, 32%, 28%, and 66%, reflecting an increasing probability of new lesions developing at later time points. Ten patients developed subependymal recurrences, of whom 7 developed multiple subependymal lesions.

CONCLUSIONS

Whereas central recurrence of glioblastoma treated with radiation and temozolomide predominates and persists over time, new in-field, marginal, and distant recurrences commonly develop, particularly at later time points in patients with longer survival.

Stereotactic radiosurgery for spinal metastases: case report and review of treatment options

The spine is the most common site for bone metastases. Spinal metastases can impact quality of life by causing severe pain, limitation of motion, and increased requirements for pain medication. Radiation therapy is a common form of treatment reserved for palliation of pain and for prevention or treatment of spinal cord compression. Newer approaches such as stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) have a more precise ability to customize the radiation dose to the target tissues adjacent to critical structures, thus increasing the local control of spinal column metastases. In this report, we examine the efficacy and possible advantages of single fraction SRS using a state-of-the-art tomotherapy machine in the treatment of a patient with spinal metastases from breast cancer. We also review the literature on treatment of spinal metastases using SRS, SBRT, and other modalities.

Stereotactic radiosurgery for glioblastoma: retrospective analysis

Purpose

This retrospective study was done to better understand the conditions for which stereotactic radiosurgery (SRS) for glioblastoma may be efficacious.

Methods

Between 2000 and 2007, 33 patients with a pathological diagnosis of glioblastoma received SRS with the Novalis^® Shaped Beam Radiosurgery system. Eighteen patients (54%) underwent salvage SRS for recurrence while 15 (45%) patients received upfront SRS following standard fractionated RT for newly diagnosed glioblastoma.

Results

There were no RTOG grade >2 acute side effects. The median survival after SRS was 6.7 months (range 1.4 – 74.7). There was no significant difference in overall survival (from the time of initial diagnosis) with respect to the timing of SRS (p = 0.2). There was significantly better progression free survival in patients treated with SRS as consolidation versus at the time of recurrence (p = 0.04). The majority of patients failed within or at the margin of the SRS treatment volume (21/26 evaluable for recurrence).

Conclusion

SRS is well tolerated in the treatment of glioblastoma. As there was no difference in survival whether SRS is delivered upfront or at recurrence, the treatment for each patient should be individualized. Future studies are needed to identify patients most likely to respond to SRS.